Contraception
Dr Chaambwa H
Obstetrician and Gynaecologist
September 2017
Methods of Contraception
Contraception is the prevention of conception by methods other than
abstinence.
It is used to limit the size or space the family
(birth control)
or
(Family planning)
Dr Chaambwa H, OBGY
Ideal Contraception
An ideal contraception should fulfill the following:
Highly efficient
Free from unwanted side effect
Absolute safety
Independent of intercourse
Simplicity of use
Reversible
Well tolerated
Dr Chaambwa H, OBGY
Methods of Contraception
The following is an overview of the currently available methods of
contraception:
Dr Chaambwa H, OBGY
Barrier Methods
Have been the most widely used contraceptive
technique throughout recorded history.
The condom –male and female
Diaphragms and cervical caps
sponge
Spermicides
Dr Chaambwa H, OBGY
Hormonal Methods
Combined
Combined Oral contraceptive pills
Combined hormonal patches
Combined vaginal rings
Progestogen only preparations
Progestogen only pills
Injectable contraceptives
Subdermal Implants
Dr Chaambwa H, OBGY
Intrauterine contraception
Copper intrauterine contraceptive device (IUCD)
Hormone releasing intrauterine system
Dr Chaambwa H, OBGY
Sterilization
Vasectomy
Female sterilization
Dr Chaambwa H, OBGY
Natural family planning
Coitus interruptus
Fertility awareness methods
Billings (cervical mucus)
Basal body temp
Calender
Lactational amenorrhoea
Dr Chaambwa H, OBGY
Efficacy of contraceptive methods
Virtually all methods occasionally fail.
Some are much more effective than others
Pearl index(failure rate): is expressed as the number of failure per
100women years(HWY). That is the number of pregnancies occurring if 100
women were to use a method for 1 year
Dr Chaambwa H, OBGY
Contraceptive method Failure rate per 100 women-years
Perfect use Typical use
Combined oral contraceptive pill 0.1 3
Progestogen -only pill 1.1 9.6
Depo-Provera 0.1 2
Implant 0.05 0.05
Copper-bearing IUD 0.8 3
Levonorgestrel-releasing IUD 0.5 0.5
Male condom 2-5 15
Female diaphragm 5 16
Female condom 21 21
Natural family planning 2-3 28
Vasectomy 0.02 0.15
Female sterilization 0.13 0.5
LAM 2
No method
Dr Chaambwa H, OBGY 85
Barrier Methods
The condom
Simple
Effective methods of contraception- 85 to 98% success rate
Without side effects
Available
Reduce the risk of STIs, HIV and cervical neoplasia
Dr Chaambwa H, OBGY
Diaphragms and Cervical Caps and The
Sponge
The diaphragms and cervical caps should be used with spermicide
Failure rate 5-16 %
The sponge is known in the U.K and the USA
Advantage of the sponge in that it can be left for 24 hours in the vagina
,besides that one size fits all women
Dr Chaambwa H, OBGY
Diaphragm
Dr Chaambwa H, OBGY
Spermicides
In the form of creams, gel aerosols, melting suppositories and foaming
tablets
Used alone
Failure rate 10- 15 %
Dr Chaambwa H, OBGY
Hormonal Methods
Oral contraception
Two types:
Combined oral contraceptive pill: most commonly used ( combination
of estrogen and progestogen) e.g
Microgynon
Safeplan
oralconF
Progestogen only pill : mini pill
e.g
Microlut
Dr Chaambwa H, OBGY
Combined oral contraceptives (COCs)
Consists of oestrogen (E) and progestin (P)
Monophasic pills - same dose of E/P all through the course
Biphasic pills - fixed dose or E/P & more P in the last 14/7
Triphasic pills - variable dose of E/P
Sequential pills - fixed dose of E, No P for first 7/7 then P for 14/7
Note that biphasic, triphasic and sequential pills are not in common use
Dr Chaambwa H, OBGY
Combined oral contraceptives
Mechanism of action
Prevents ovulation by inhibiting gonadotrophin secretion via an effect on both
pituitary and hypothalamic centres
The progestin suppresses LH secretion (& thus prevents ovulation, while the
oestrogenic agent suppresses FSH secretion (& thus prevents the selection and
emergence of a dominant follicle
Dr Chaambwa H, OBGY
Efficacy of COC
Typical usage is associated with a 3.0% failure rate during the first year of use
Efficacy decreases significantly when the oestrogen component is removed
Dr Chaambwa H, OBGY
Absolute contraindications to COC use
Thrombophlebitis, thromboembolic Undiagnosed abnormal vaginal
disorders, CVA, coronary occlusion bleeding
Markedly impaired liver function known or suspected pregnancy
Known or suspected breast cancer Smokers over the age of 35 years
Dr Chaambwa H, OBGY
Relative contraindications to COC use
Migraine headaches H/O obstructive jaundice in
pregnancy
Hypertension
Sickle cell disease or sickle C
H/O gestational diabetes
disease
Elective surgery Diabetes mellitus
Epilepsy Gall bladder disease
Dr Chaambwa H, OBGY
Clinical problems associated with COCs
Breakthrough bleeding Drugs that affect efficacy
Amenorrhoea Migraine headaches
weight gain
Acne; rarely
Dr Chaambwa H, OBGY
Drug interaction
Effect of other drugs Effect of COCs
on COC
Enzyme inducing drugs e.g. (a) barbiturates
(b) all antiepileptic drugs except sodium
on ther drugs
valproate and clonazepam (c) rifampicin (d) Effectiveness of some drugs
ketoconazole (e) griseofulvin (f) ritonavir (g) (Aspirin, oral anticoagulants, oral
nevirapine
hypoglycaemics) are decreased
Some broad spectrum antibiotics amoxicillin,
tetracycline, doxycycline — as they impair and that for some other drugs
the absorption of ethinyl estradiol (beta blockers, corticosteroids,
under such circumstances high dose diazepam, aminophylline) are
preparations (ethinyl estradiol of 50 µg or increased by oral contraceptives.
more) are to be used or barrier method is
employed.
Dr Chaambwa H, OBGY
Non-Contraceptive Benefits of OCs
These can broadly be grouped into two main categories:
Benefits that incidentally accrue when COCs is specifically utilized for
contraception &;
Benefits that result from the use of COCs to treat problems or disorders
Dr Chaambwa H, OBGY
Non contraceptive incidental benefits of
OCs
less PID
less endometrial cancer less rheumatoid arthritis
less ovarian cancer increased bone density
fewer ectopic less endometriosis
pregnancies. less benign breast disease
more regular menses fewer ovarian cysts
Less anaemia
Dr Chaambwa H, OBGY
COCs as treatment
DUB hormone therapy for hypothalamic
amenorrhoea
dysmenorrhoea
control of bleeding
mittelschmerz
premenstrual syndrome
endometriosis prophylaxis
acne & hirsutism
Dr Chaambwa H, OBGY
Pill taking
Effective contraception is present during the first cycle of pill use, provided
the pills are started no later than the 5th day of the cycle and no pills are
missed
Dr Chaambwa H, OBGY
Missed Pills
If a woman misses 1 or 2 pills, she should take the most recent missed pill as
soon as she remembers. She should continue taking the remaining pills daily
at her usual time. No back-up is needed.
If she misses 3 or more pills at any time, she should take the most recent
missed pill as soon as she remembers. She should continue taking the
remaining pills daily at her usual time. Back-up is needed for the next 7 days
Dr Chaambwa H, OBGY
Missed pills cont
In addition, if 3 or more pills are missed in the first week, emergency
contraception should be considered if she had sex.
If pills are missed in the 3rd week, she should finish the pills in her current
pack and start a new pack the next day, thus omitting the pill free interval
Dr Chaambwa H, OBGY
Combined Oral Contraceptives
Advantages
These are simple to use and highly effective
No special preparation is necessary before intercourse
The pill may relieve irregular menstrual periods, cramps and premenstrual
tension
Dr Chaambwa H, OBGY
The Progestin-Only Pill (POP) Mini pill
The mini pill contains a small dose of progestogen agent (25% of that in COC)
and must be taken daily, in a continuous fashion
Dr Chaambwa H, OBGY
Mechanism of Action - POP
The contraceptive effect is more dependent upon endometrial and cervical
mucus effects, since the gonadotrophins are not consistently suppressed
The endometrium involutes and becomes hostile to implantation and the
cervical mucus becomes thick and impermeable
Dr Chaambwa H, OBGY
POP cont’d
There are no significant metabolic effects (lipid levels, CHO metabolism and
coagulation factors remain unchanged)
There is an immediate return to fertility upon discontinuation
Failure rates range form 1.1 to 9.6% per 100 women in the first year of use
Dr Chaambwa H, OBGY
POP cont’d
Pill taking
The mini pill should be started on the first day of menses and a back-up
method must be used for the first 7 days
The pill should be taken at the same time of the day
If more than 3 hours late in taking a pill, a back-up method should be used for
48 hours
Dr Chaambwa H, OBGY
Problems associated with POP
POP have unpredictable effect on 20% total lack of cycles ranging
ovulation from irregular bleeding to spotting
and amenorrhoea
40% of patients can expect to have
normal ovulatory cycles development of functional cysts
40% short irregular cycles levonorgestrel minipill may be
associated with acne
Dr Chaambwa H, OBGY
POP
There are two situations where excellent efficacy is achieved:
In lactating women, the contribution of the minipill is combined with
prolactin-induced suppression of ovulation adding up to very effective
protection
In women over age 40, reduced fecundity adds to the minipill’s effects.
Dr Chaambwa H, OBGY
Implant contraception - NORPLANT
Progestin circulating at levels 1/4 to 1/10th of those in COC, prevents
conception by suppressing ovulation and thickening cervical mucus to inhibit
sperm penetration
Side effects include changes in menstrual pattern, weight gain, headache,
and effects on mood
Dr Chaambwa H, OBGY
NORPLANT
consists of 6 capsules 34mm in the capsules release ~ 80 micro
length, 2.4 mm outer diameter, grams of levonorgestrel per 24
containing 36 mm crystalline hours during the first 6-12 months
levonorgestrel. of use
the 6 capsules contain a total of once inserted have an effective life
216 mg of levonorgestrel which is of 5 years
very stable
Dr Chaambwa H, OBGY
The mechanism of action
Suppression at both the hypothalamic and pituiatry LH surge necessary for
ovulation
The constant level of progestin has a marked effect on the cervical mucus
Suppression of the estradiol-induced cyclic maturation of the endometrium
and eventually causes atrophy
Dr Chaambwa H, OBGY
Disadvantages of NORPLANT
disruption of bleeding patterns in implants can be visible under the
up to 80% of users naked eye
implants must be inserted and does not protect against STI/HIV
removed in a surgical procedure by acne
trained personnel
Dr Chaambwa H, OBGY
Absolute contraindications
active thrombophlebitis or benign or malignant liver tumours
thromboemboilc phenomena known or suspected breast cancer
undiagnosed genital bleeding
acute liver disease
Dr Chaambwa H, OBGY
IMPLANON
A single implant 4 cm long contains 60 mg of 3-keto desogestrel
The hormone is released at a rate of about 60 micro grams per day
Is designed to provide contraception for 2-3 years
Efficacy and side effects are similar to those of NORPLANT
Dr Chaambwa H, OBGY
Jadelle
Two rods containing 75mg LNG crystals embedded in a coplolymer and
encased in silastic tubing
Rods are 43mm long and 2.5mm wide
Lasts for 5 years
Rods are easier and more convenient to insert and remove
Norplant and Jadelle are bioequivalent over 5 years of use
Dr Chaambwa H, OBGY
Injectable Contraception:
Depo-Provera
Comes as microcrystals, suspended in an aqueous solution
Correct dose is depot medroxyprogestrone acetate 150 mg IM (gluteal or
deltoid) every 3 months
Relies on higher peaks of progestin to inhibit ovulation and thicken cervical
mucus. The progestin level is high enough to block the LH surge
Dr Chaambwa H, OBGY
Depo-Provera
cont’d
The injection should be given within the first 5 days of the current menstrual
cycle, otherwise a back-up method is necessary for 2 weeks
The injection must be given deeply in muscle by the Z-track technique and
not massaged
Dr Chaambwa H, OBGY
Depo-Provera
Advantages
easy to use, no daily or coital free from estrogen related
acton required problems
safe no serious health effects private use not detectable
effective as sterilization, IUCD & enhances lactation
implant contraception has non contraceptive benefits
Dr Chaambwa H, OBGY
Depo-Provera
Disadvantages
irregular menstrual bleeding can’t be removed
breast tenderness return to fertility is delayed
weight gain regular injections required
depression no STI/HIV protection
Dr Chaambwa H, OBGY
Depo-Provera
Absolute contraindications
Pregnancy
Unexplained genital bleeding
Dr Chaambwa H, OBGY
Injectable Contraception:
Noristerat
Norethisterone enanthate 200mg
Given every 2 months
Similar to Depot provera in all areas
Dr Chaambwa H, OBGY
Intrauterine Contraception
Types of IUDS
Copper IUDs - TCu-380A
Hormone-releasing IUDs (LNG-IUS) - mirena
Dr Chaambwa H, OBGY
IUCD
Mechanism of Action
The mechanism of action is the production of an intrauterine environment
that is spermicidal and interfere with implantation
Ovulation is not affected nor is the IUCD an abortifacient
Abortifacient means “causing abortion”
Dr Chaambwa H, OBGY
Efficacy of IUDS
The actual failure rate in the first year is approximately 3%, with a 10%
expulsion rate, and a 15% rate of removal, mainly for bleeding and pain.
The non medicated IUDs never have to be replaced
Dr Chaambwa H, OBGY
Timing of IUCD insertion
An IUCD can be safely inserted at any time; after delivery, abortion or during
the menstrual cycle
The IUCD can also be inserted at Caesarean section
Dr Chaambwa H, OBGY
IUCD Use
contraindications
Presence of pelvic infection current or within 3 months;
Undiagnosed genital tract bleeding;
Suspected pregnancy;
Distortion of the shape of the uterine cavity as in fibroid or congenital uterine-malformation;
Past history of ectopic pregnancy;
Trophoblastic disease;
Additionally for CuT380A are: Wilson disease and Copper allergy.
Dr Chaambwa H, OBGY
Pregnancy with IUD in situ
Spontaneous abortion - 40-50%, IUDs should be removed if pregnancy is
diagnosed and the strings are visible and pregnancy less than 12weeks
Removal may trigger an abortion, hence it may be justified to leave it
especially if pregnancy is 12 or more weeks of gestation or if strings not
visible.
Pre-term labour and birth - incidence is increased 4-fold
Dr Chaambwa H, OBGY
Missing strings
The thread may not be visible through the cervical os due to —
Thread coiled inside;
Thread torn through;
Device expelled outside unnoticed by the patient;
Device perforated the uterine wall and is lying in the peritoneal cavity;
Device pulled up by the growing uterus in pregnancy.
Methods of identification:
Ultrasonography can detect the IUD either within the uterine cavity or in the
peritoneal cavity (if perforated).
Dr Chaambwa H, OBGY
Natural family planning
Coitus interruptus
Fertility awareness methods
Billings (cervical mucus)
Basal body temp
Calendar
Lactational amenorrhoea
Dr Chaambwa H, OBGY
Coitus interruptus
Involves removal of the penis from the vagina before ejaculation takes place
1st year failure rate - 18%
Some sperm may be released before ejaculation
Is a better method than using no method at all
Dr Chaambwa H, OBGY
Fertility awareness
Is keyed to the observation of naturally occurring signs and symptoms of the
fertile phase of the menstrual cycle.
It takes into account the viability of sperm in the female reproductive tract
and the life span of the ovum
Dr Chaambwa H, OBGY
Methods of fertility awareness
Rhythm of Calendar method
Fertile period is calculated
Cervical Mucus method
During the fertile period and relative infertility period, the cervical mucus is copious, while during
the absolute infertile period there is no cervical mucus
Basal body temperature method
The rise in temp of 0.5 for 3 days indicate luteal phase
Dr Chaambwa H, OBGY
Lactational Amennorrhoea Method (LAM)
High concentrations of prolactin work at both central and ovarian sites to
produce lactational amenorrhoea and anovulation
Elevated levels of prolactin inhibit the pulsatile secretion of GnRH
Dr Chaambwa H, OBGY
LAM
Only amenorrhoeic women who exclusively breastfeed at regular intervals,
including at nighttime, during the first 6 months have the contraceptive
protection equivalent to the provided by oral contraception
Dr Chaambwa H, OBGY
LAM
With menstruation or after 6 months, the risk of ovulation increases
Supplemental feeding increases the risk of ovulation (and pregnancy) even in
amenorrheic women
Dr Chaambwa H, OBGY
B/feeding and Contraception
The rule of 3s
In the presence of FULL b/feeding, a contraceptive method should be used
beginning in the 3rd postpartum month
With PARTIAL b/feeding or NO b/feeding, a contraceptive method should
begin during the 3rd postpartum week
Dr Chaambwa H, OBGY
B/feeding and Contraception
Combined Oral contraceptives even in low doses diminishes the quantity and
quality of breast milk
Progestogen only contraceptives do not affect breast feeding
Dr Chaambwa H, OBGY
Sterilization
Female and male sterilization are permanent methods of contraception and
are highly effective
Indicated in clients with satisfied parity or with medical conditions precluding
pregnancy
Dr Chaambwa H, OBGY
Female Sterilization
Mechanical blockage/ excision of both fallopian tubes
Can be done laparoscopy, laparotomy, mini-lap
Timing:
during caesarean section,
puerperal, or
interval
Dr Chaambwa H, OBGY
Male Sterilization
Excision of the vas deferens to prevent release of sperm during ejaculation
It is easier quicker and more straightforward than female sterilization
It is not effective immediately : may take up to 3 to 4 months
Hence alternate method should be used until azoospermia confirmed.
Dr Chaambwa H, OBGY
Emergency Contraception
Emergency contraception methods can prevent pregnancy after unprotected
intercourse, method failure or incorrect method use
Can help reduce unplanned pregnancies, many of which result in unsafe
abortion
Prescribed within 72 hours of unprotected sex. For IUCD it can be inserted up
to 5days after unprotected sex
Dr Chaambwa H, OBGY
Emergency contraception methods
Progestin only pills
Intra uterine contraceptive device
Combined oral contraceptive pills
Dr Chaambwa H, OBGY
POP
Single dose 1500mcg of Levonorgestrel
Two doses of 750mcg Levonorgestrel taken 12hry apart
Dr Chaambwa H, OBGY
POP
Ovrette - 20 tablets per dose, each tablet contains 0.0375 mg Levonorgestrel
Microlut, Microval, Norgestron - 25 tablets per dose, each tablet contains
0.03mg Levonorgestrel
Dr Chaambwa H, OBGY
IUCDs
Copper T
Insertion within 120 hours (five days) of unprotected intercourse
Dr Chaambwa H, OBGY
Oral contraceptive pills
Emergency contraceptive pills use the same ingredients as regular
contraceptives
Should be initiated ideally within 3 days (72 hours) of unprotected intercourse
Should be taken in two doses 12 hours apart
Dr Chaambwa H, OBGY
COC
Each of the two doses of COC should contain at least 100 ug (0.10 mg) Ethinyl
Estradiol (EE) and 500 ug (0.50 mg) Levonorgestrel
Dr Chaambwa H, OBGY
COC
PC-4, Eugoynon 50, Neogynon, Noral, Nordiol, Ovidon, Ovral, Ovran
Two tablets per dose: each tablet contains 50 ug EE & either 0.25mg or 0.50
mg levonorgestrel
Dr Chaambwa H, OBGY
COC
LoFemenal, Microgynon 30, Nordette, Ovral L, Rigevidon
Four tablets per dose: each tablet contains 30 ug EE & either 0.15 mg or 0.30
mg Levonorgestrel
Dr Chaambwa H, OBGY
Conclusion
The world population is around 6 billion , four hundred million couples
are practicing a family planning, many couples around the world who are
motivated to practice family planning lack the sources or the methods
suitable for their needs.
At least one method may be suitable for each couple at any given time in
order to plan their families and avoid unwanted pregnancy.
Dr Chaambwa H, OBGY
The end
Dr Chaambwa H, OBGY
